High-throughput low-cost nl-qPCR for enteropathogen detection: A proof-of-concept among hospitalized patients in Bangladesh.

BACKGROUND: Diarrheal disease is a leading cause of morbidity and mortality globally, especially in low- and middle-income countries. High-throughput and low-cost approaches to identify etiologic agents are needed to guide public health mitigation. Nanoliter-qPCR (nl-qPCR) is an attractive alternative to more expensive methods yet is nascent in application and without a proof-of-concept among hospitalized patients. METHODS: A census-based study was conducted among diarrheal patients admitted at two government hospitals in rural Bangladesh during a diarrheal outbreak period. DNA was extracted from stool samples and assayed by nl-qPCR for common bacterial, protozoan, and helminth enteropathogens as the primary outcome. RESULTS: A total of 961 patients were enrolled; stool samples were collected from 827 patients. Enteropathogens were detected in 69% of patient samples; More than one enteropathogen was detected in 32%. Enteropathogens most commonly detected were enteroaggregative Escherichia coli (26.0%), Shiga toxin-producing E.coli (18.3%), enterotoxigenic E. coli (15.5% heat stable toxin positive, 2.2% heat labile toxin positive), Shigella spp. (14.8%), and Vibrio cholerae (9.0%). Geospatial analysis revealed that the median number of pathogens per patient and the proportion of cases presenting with severe dehydration were greatest amongst patients residing closest to the study hospitals." CONCLUSIONS: This study demonstrates a proof-of-concept for nl-qPCR as a high-throughput low-cost method for enteropathogen detection among hospitalized patients.

Introduction of Zika virus in Bangladesh: An impending public health threat.

OBJECTIVE: To explore the presence of Zika virus (ZIKV) in Bangladesh and to understand the associated risk factors. METHODS: A retrospective sero-surveillance was performed on stored serum samples of dengue surveillance conducted from 2013 to 2016. Real time RT-PCR was performed on randomly selected acute serum samples to detect the Zika virus nucleic acid. RESULTS: Of 200 samples screened, one was found positive for ZIKV by real time RT-PCR and further confirmed by genome sequencing. The case was a 65 years old male from a metropolitan city of Bangladesh who had no history of travel outside Bangladesh. Phylogenetic analysis of partial E gene sequences from Bangladeshi isolates demonstrated a close relationship with ZIKV from Brazil and current South American strains clustering within a monophyletic clade distinct from African lineage. CONCLUSIONS: Presence of ZIKV raises serious public health concerns in Bangladesh owing to its association with congenital anomalies/neurological-manifestations. We, therefore, recommend every suspected viral fever patient, particularly pregnant women be screened for ZIKV infection to rule out yet another emerging infection in Bangladesh.

Evaluation of a Smartphone Decision-Support Tool for Diarrheal Disease Management in a Resource-Limited Setting.

The emergence of mobile technology offers new opportunities to improve clinical guideline adherence in resource-limited settings. We conducted a clinical pilot study in rural Bangladesh to evaluate the impact of a smartphone adaptation of the World Health Organization (WHO) diarrheal disease management guidelines, including a modality for age-based weight estimation. Software development was guided by end-user input and evaluated in a resource-limited district and sub-district hospital during the fall 2015 cholera season; both hospitals lacked scales which necessitated weight estimation. The study consisted of a 6 week pre-intervention and 6 week intervention period with a 10-day post-discharge follow-up. Standard of care was maintained throughout the study with the exception that admitting clinicians used the tool during the intervention. Inclusion criteria were patients two months of age and older with uncomplicated diarrheal disease. The primary outcome was adherence to guidelines for prescriptions of intravenous (IV) fluids, antibiotics and zinc. A total of 841 patients were enrolled (325 pre-intervention; 516 intervention). During the intervention, the proportion of prescriptions for IV fluids decreased at the district and sub-district hospitals (both p < 0.001) with risk ratios (RRs) of 0.5 and 0.2, respectively. However, when IV fluids were prescribed, the volume better adhered to recommendations. The proportion of prescriptions for the recommended antibiotic azithromycin increased (p < 0.001 district; p = 0.035 sub-district) with RRs of 6.9 (district) and 1.6 (sub-district) while prescriptions for other antibiotics decreased; zinc adherence increased. Limitations included an absence of a concurrent control group and no independent dehydration assessment during the pre-intervention. Despite limitations, opportunities were identified to improve clinical care, including better assessment, weight estimation, and fluid/ antibiotic selection. These findings demonstrate that a smartphone-based tool can improve guideline adherence. This study should serve as a catalyst for a randomized controlled trial to expand on the findings and address limitations.

An Outbreak of Chikungunya in Rural Bangladesh, 2011.

BACKGROUND: The first identified Chikungunya outbreak occurred in Bangladesh in 2008. In late October 2011, a local health official from Dohar Sub-district, Dhaka District, reported an outbreak of undiagnosed fever and joint pain. We investigated the outbreak to confirm the etiology, describe the clinical presentation, and identify associated vectors. METHODOLOGY: During November 2-21, 2011, we conducted house-to-house surveys to identify suspected cases, defined as any inhabitant of Char Kushai village with fever followed by joint pain in the extremities with onset since August 15, 2011. We collected blood specimens and clinical histories from self-selected suspected cases using a structured questionnaire. Blood samples were tested for IgM antibodies against Chikungunya virus. The village was divided into nine segments and we collected mosquito larvae from water containers in seven randomly selected houses in each segment. We calculated the Breteau index for the village and identified the mosquito species. RESULTS: The attack rate was 29% (1105/3840) and 29% of households surveyed had at least one suspected case: 15% had ≥3. The attack rate was 38% (606/1589) in adult women and 25% in adult men (320/1287). Among the 1105 suspected case-patients, 245 self-selected for testing and 80% of those (196/245) had IgM antibodies. In addition to fever and joint pain, 76% (148/196) of confirmed cases had rash and 38%(75/196) had long-lasting joint pain. The village Breteau index was 35 per 100 and 89%(449/504) of hatched mosquitoes were Aedes albopictus. CONCLUSION: The evidence suggests that this outbreak was due to Chikungunya. The high attack rate suggests that the infection was new to this area, and the increased risk among adult women suggests that risk of transmission may have been higher around households. Chikungunya is an emerging infection in Bangladesh and current surveillance and prevention strategies are insufficient to mount an effective public health response.

Early detection of pandemic (H1N1) 2009, Bangladesh.

To explore Bangladesh's ability to detect novel influenza, we examined a series of laboratory-confirmed pandemic (H1N1) 2009 cases. During June-July 2009, event-based surveillance identified 30 case-patients (57% travelers); starting July 29, sentinel sites identified 252 case-patients (1% travelers). Surveillance facilitated response weeks before the spread of pandemic (H1N1) 2009 infection to the general population.

Fatal outbreak from consuming Xanthium strumarium seedlings during time of food scarcity in northeastern Bangladesh.

BACKGROUND: An outbreak characterized by vomiting and rapid progression to unconsciousness and death was reported in Sylhet Distrct in northeastern Bangladesh following destructive monsoon floods in November 2007. METHODS AND FINDINGS: We identified cases presenting to local hospitals and described their clinical signs and symptoms. We interviewed patients and their families to collect illness histories and generate hypotheses about exposures associated with disease. An epidemiological study was conducted in two outbreak villages to investigate risk factors for developing illness. 76 patients were identified from 9 villages; 25% (19/76) died. Common presenting symptoms included vomiting, elevated liver enzymes, and altered mental status. In-depth interviews with 33 cases revealed that 31 (94%) had consumed ghagra shak, an uncultivated plant, in the hours before illness onset. Ghagra shak was consumed as a main meal by villagers due to inaccessibility of other foods following destructive monsoon flooding and rises in global food prices. Persons who ate this plant were 34.2 times more likely (95% CI 10.2 to 115.8, p-value<0.000) than others to develop vomiting and unconsciousness during the outbreak in our multivariate model. Ghagra shak is the local name for Xanthium strumarium, or common cocklebur. CONCLUSIONS: The consumption of Xanthium strumarium seedlings in large quantities, due to inaccessibility of other foods, caused this outbreak. The toxic chemical in the plant, carboxyatratyloside, has been previously described and eating X. strumarium seeds and seedlings has been associated with fatalities in humans and livestock. Unless people are able to meet their nutritional requirements with safe foods, they will continue to be at risk for poor health outcomes beyond undernutrition.

Socio-economic determinants of low birth weight in Bangladesh: a multivariate approach.

Though the health situation of Bangladesh has improved substantially over the years, the low birth weight (LBW) rate is still pretty high. The principal focus of this study was to ascertain the significant determinants for LBW. One hundred and eight LBW babies were compared with 357 normal birth weight babies. Out of 20 possible risk variables analyzed, 9 were found significant when studied separately. Mother's age, education, occupation, yearly income, gravid status, gestational age at first visit, number of antenatal care visit attended, quality of antenatal care received and pre-delivery body mass index had significantly associated with the incidence of LBW. Using the stepwise logistic regression, mother's age (p < 0.001), education (p < 0.02), number of antenatal care visit attended (p < 0.001, OR = 29.386) and yearly income (p < 0.001, OR = 3.379) created the best model, which predicted 86.1% and 94.4% of the LBW babies and normal birth weight babies respectively. Maternal age, educational level and economic status play an important role in the incidence of low birth weight.

Quality of antenatal care and its dose-response relationship with birth weight in a maternal and child health training institute in Bangladesh.

Four hundred and sixty-five pregnant women and their newborn babies were studied at a maternal and child health training institute in Dhaka, Bangladesh, between July 2002 and June 2003 with the objective of (1) examining the relationship between birth weight and maternal factors, and, if there was a dose-response relationship between quality of antenatal care and birth weight, (2) predicting the number of antenatal visits required for women with different significant characteristics to reduce the incidence of low-birth-weight babies. The study revealed that 23.2% of the babies were of low birth weight according to the WHO cut-off point of <2500 g. Mean birth weight was 2674.19+/-425.31 g. A low birth weight was more common in younger (<20 years) and older (> or =30 years) mothers, the low-income group and those with little or no education. The mean birth weight of the babies increased with an increase in quality of antenatal care. The babies of the mothers who had 6+ antenatal visits were found to be 727.26 g heavier than those who had 1-3 visits and 325.88 g heavier than those who had 4-5 visits. No significant relationship was found between number of conception, birth-to-conception interval, BMI at first visit, sex of the newborn and birth weight. Further, from multiple regression analysis (stepwise), it was revealed that number of antenatal visits, educational level of the mother and per capita yearly income had independent effects on birth weight after controlling the effect of each variable. Using multiple regression analysis, the estimated number of antenatal visits required to reduce the incidence of low-birth-weight babies for women with no education and below-average per capita income status was 6; the number required for women with no education and above-average per capita income status was 5; and that for women with education and with any category of income status was 4 visits. So there is a need to stratify women according to their income and educational status so that, along with other measures, the required number of antenatal visits can be estimated beforehand to reduce the incidence of low-birth-weight babies.